We have developed case studies to show how community-based services work now, and how, with our new care model, they could work in the future.

Jim is 71 and lives in Stoke-on-Trent with his wife, Janice. He has multiple medical conditions including Parkinson’s disease and has recently had several falls both at home and when walking to his local shop.

Jim has just fallen again in his hallway at home and can’t get up. Jim calls for help and eventually Janice hears his cries over the noise of the television. She calls 999.

Current model of care delivery

The paramedics arrive and take him to the A&E department at the Royal Stoke University Hospital. He is assessed in A&E and deemed not to have broken anything. However, given the frequency of his falls,he is admitted for review by the neurologists and geriatricians.

On the ward, Jim receives good quality clinical care and is treated with safety and dignity, but he misses being in his own bed and doesn’t sleep very well. Janice finds it difficult and stressful to travel each day to the hospital and worries about what will happen when Jim comes home again.

After three days, Jim is discharged home with a note to his GP recommending review by community therapy teams. Both he and Janice nervously await his next fall.

Proposed model of care delivery

The paramedics arrive and get Jim back on his feet. They contact the local integrated care hub, who, on hearing about Jim’s situation, send outa clinician from the Home First service.

The nurse arrives within two hours of the referral being made, gives Jim a full assessment and checks how Janice is feeling too. Picking up how low Janice is, the nurse puts in place a two-week care package starting that night, including input from community nursing, occupational therapy, physiotherapy, social care and the falls responder service.

During the two-week period, a mental health nurse and social worker also visit to talk to Janice and ask her how she is coping both practically and emotionally and if she needs any support.

The couple know that if Jim falls again, they can call the integrated care team based at the hub for help. Jim and Janice feel supported and able to live with renewed feelings of independence and control.

Florence is 94 and lives in Staffordshire Moorlands with her daughter. She has diabetes controlled with tablets and osteoarthritis which is causing her pain in her hip. Despite this, she has always prided herself on being active.

Florence has just been discharged home after a hospital stay for a chest infection. She is finding it difficult to return to the levels of confidence she previously had to carry out everyday tasks herself, saying her hip is now especially painful. Her blood sugar levels are now not as well controlled as they had been in the past.

Florence’s daughter can’t be there for her mother all day every day to make sure she takes her diabetes medication, washes, eats and stays clean.

Current model of care delivery

Florence’s daughter investigates with her GP the option of respite care, where her mother’s health needs as well as her social care needs can be cared for. However, Florence is reluctant to go. It's not a place she would ever hope to find herself in, although she understands it’s for her own benefit.

After a couple of weeks in the care home, Florence has become depressed: she misses her freedom to potter about the garden, speak to the neighbours, and choose what to do when. When it comes time for her to leave and return home, the GP and Florence’s daughter both express concern that Florence is, if anything, less able now than before to live on her own.

A social care assessment offers a high-level package of support for her to return home. Florence and her daughter travel every six weeks into Stoke-on-Trent for her follow-up outpatients appointments. By the time she gets there, Florence is too tired to concentrate on what the doctor is asking or telling her.

After a few weeks of the support package, Florence still feels as if her independence and control have been limited. Her diabetes remains difficult to control and her hip pain is still reducing her mobility. Together with her daughter, she decides it is time for her to move permanently to a care home.

Proposed model of care delivery

Florence’s daughter speaks to her GP who refers Florence’s case to the local integrated care team. Her local integrated care team visits in the mornings and evenings for just over a week to help Florence get back to walking independently, washing and dressing herself again, and to make sure she takes her medication routinely and is confident to make snacks and drinks herself.

Within a week of their initial visit, Florence’s confidence has started to return. She is able to get in and out of the bath by herself, make a cup of tea and sleeps well. Her diabetes has come back under control and her hip pain doesn’t seem to bother her so much. Instead of having follow-up outpatient care at the local community hospital, Florence is able to visit her local integrated care hub where her local specialist team is located.

Florence is comfortable in her own environment and knows that if she needs help again, it is only a call away.